Psychiatric comorbidities in patients with headaches

Impulsiveness levels among patients with medication-overuse headache accompanying chronic migraine or tension-type headache

Impulsiveness in primary headaches is not well understood.To analyze impulsiveness in patients with medication-overuse headache (MOH) and either chronic migraines or chronic tension-type headaches (TTHs).This cross-sectional study included 119 participants (96 female) divided into 3 groups: the migraine with MOH (M-O, n = 44, age = 36.6 ± 11.1), the tension-type headache with MOH group (TTH-O, n = 38, age = 42.6 ± 11.8), and the healthy control group (HC, n = 37, age = 36.9 ± 13.1). The Barratt Impulsiveness Scale-11 Short Form (BIS-11 SF), Beck's Depression Inventory (BDI), Beck's Anxiety Inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) were used to assess impulsiveness, depression, anxiety, and sleep quality, respectively.Impulsiveness levels were significantly higher in the M-O (p < 0.01) and TTH-O (p < 0.01) groups compared with the HC. However, no significant difference in impulsiveness was found between the M-O and TTH-O (p > 0.05). The PSQI scores were significantly higher in the M-O and TTH-O compared with the HC (p < 0.01). Additionally, anxiety scores were notably higher in the M-O compared with both the TTH-O and HC (p < 0.01).The present study, which compared the M-O and TTH-O groups with HC in terms of impulsiveness, with no significant differences in parameters such as age, gender, schooling, frequency of headache attacks, and disease onset duration, concluded that both patient groups exhibited higher impulsiveness compared with the controls. Furthermore, the lack of difference in impulsiveness between MO and chronic TTH-O patients with a common denominator of MOH suggests that it may be associated with MOH, which is a shared subset of two distinct headache disorders.

Prevalence and Correlates of Psychiatric Comorbidity and Multimorbidity in Parkinson's Disease and Atypical Parkinsonian Syndromes

PURPOSE

Psychiatric comorbidity in Parkinson's disease (PD) and atypical parkinsonian syndromes (APS) has been consistently associated with poor outcomes. However, the co-occurrence of multiple psychiatric disorders has been sparsely studied. This study examines the prevalence, patterns, and correlates of psychiatric comorbidity and multimorbidity among in-patients hospitalised with PD/APS.

METHODS

Patients (N-110 [PD-71, APS-39]) underwent a single cross-sectional assessment. Psychiatric comorbidity was examined using the Mini International Neuropsychiatric Interview. Other domains assessed include sleep disorders, quality of life, and caregiver burden.

STATISTICAL ANALYSIS

In addition to descriptive statistics, multinomial logistic regression was used to examine the effect of sociodemographic and clinical factors on comorbidities.

RESULTS

The prevalence of psychiatric comorbidity in patients with PD and APS was 77.00% and 71.79%, with approximately half of those having co-occurrence of multiple psychiatric disorders. In both disorders, depression was the most common, followed by anxiety disorder. The two commonest patterns of multimorbidity reported in PD were the combination of depression and anxiety disorder, followed by the combination of psychosis, depression, and anxiety, with the order being reversed in APS. When compared to those without, those with single psychiatric comorbidity had higher odds of having REM sleep behaviour disorder and caregiver stress. Those with multiple psychiatric comorbidities had higher odds of being female, higher UPDRS part-1 scores, REM sleep behaviour disorder, poor sleep quality, and caregiver stress.

CONCLUSION

Psychiatric illness is highly comorbid among patients with PD/APS, with most having multiple co-occurring psychiatric illnesses. Clinicians must be aware to ensure early detection and intervention.

Clinical Outcome of Nerve Decompression Surgery for Migraine Improves with Nerve Wrap

Background:

Chronic migraine headaches affect nearly 30 million Americans every year and are responsible for roughly 1.2 million emergency department visits annually. Many of the standard therapies commonly used to treat migraines are often unsuccessful and may furthermore introduce unwanted side effects. The purpose of this study was to identify independent predictors of clinical improvement in patients undergoing surgical nerve decompression for migraine.

Methods:

A retrospective chart review between 2010 and 2020 was conducted. The primary endpoint was clinical improvement at 1-year follow-up, defined as an independence from prescription medications. Patients were stratified into two groups: clinical improvement and treatment failure. Backward multivariable logistic regression was used to examine the associations between migraine improvement and different patient characteristics.

Results:

A total of 153 patients were included. In total, 129 (84.3%) patients improved and 24 (15.7%) did not. Significant associations with clinical improvement at multivariable logistic regression were found with acellular dermal matrix nerve wrap (OR = 10.80, 95%CI: 6.18–16.27), and operation of trigger sites four (OR = 37.96, 95%CI: 2.16–73.10) and five (OR = 159, 95%CI: 10–299).

Conclusion:

The use of acellular dermal matrix nerve wraps in surgery was significantly associated with clinical migraine improvement, as was operation at trigger sites four and five.

Dihydroergotamine infusion for pediatric refractory headache: A retrospective chart review

BACKGROUND

Headaches are a common symptom in children. Children with refractory headaches may be admitted for inpatient treatment with intravenous dihydroergotamine mesylate (DHE). However, very few studies have characterized these patients and their treatment outcomes using validated, self-reported, pain scales.

OBJECTIVE

The objective of this study was to describe demographic and clinical characteristics of children admitted for DHE infusion, determine DHE treatment outcomes by means of numeric pain scale ratings, and explore associations between treatment outcomes and clinical characteristics.

METHODS

Retrospective chart review was completed in patients ages 5-21 admitted for DHE infusion from January 2013 to July 2018 at a large, pediatric academic medical center and community-based satellite center. All primary headache types were included.

RESULTS

A total of 200 unique admissions for DHE were available for analysis. Overall, patients were predominantly White (87.5%, 175/200) and female (80.0%, 160/200) with an average age of 15.4 years (SD 2.3). Common comorbidities included obesity (42.0%, 81/193), anxiety (41.0%, 82/200), and depression (20.0%, 40/200). The mean length of stay was 2.4 days (SD 1.10; range 1-8 days). Most headaches (65.0%, 130/200) met the International Classification of Headache Disorders, 3rd edition criteria for migraine, followed by new daily persistent headache (25.5%, 51/200). Mean DHE maximum dose was 5.3 (SD 2.17; range 0.5-14.5 mg) with most patients requiring 3.5-6.5 mg. DHE was typically terminated at six doses (range 1-15). The most frequently reported adverse event was nausea (5.5%, 11/200). There was no difference in pain severity at admission across headache types, with an average baseline pain score of 8.1 (SD 1.6). Posttreatment reduction in pain score was statistically significant (range: -3.2 to -4.9; each p < 0.001) across all headache types. Overall, 84.0% (168/200) of the patients had some improvement in pain. More than half of the patients (53.5%, 107/200) showed at least moderate improvement (≥50.0% reduction in pain score), and 18.0% (36/200) had full headache resolution. Limited patients (16.0%, 32/200) experienced no improvement in pain.

CONCLUSIONS

Treatment with DHE resulted in at least some improvement for most patients regardless of headache type or number of doses. Clinical trials stratified by headache type and comorbid factors could help clarify treatment algorithms to optimize patient outcomes.

Physical-Mental Comorbidity of Pediatric Migraine in the Philadelphia Neurodevelopmental Cohort

OBJECTIVE

To examine the associations between headaches and migraine with physical and mental disorders in a large pediatric registry.

STUDY DESIGN

In total, 9329 youth aged 8-21 years from the Philadelphia Neurodevelopmental Cohort were included. Physical conditions, including headache, were ascertained from electronic medical records and in-person interviews. Modified International Classification of Headache Disorders (ICHD-II) criteria were used to classify migraine symptoms. Forty-two other physical conditions were classified into 14 classes of medical disorders. Mental disorders were assessed using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia.

RESULTS

Lifetime prevalence of any headache was 45.5%, and of migraine was 22.6%. Any headache was associated with a broad range of physical disorders, attention-deficit/hyperactivity disorder (OR 1.2 [95% CI 1.1-1.4]), and behavior disorders (1.3 [1.1-1.5]). Youth with migraine had greater odds of specific physical conditions and mental disorders, including respiratory, neurologic/central nervous system, developmental, anxiety, behavior, and mood disorders than those with nonmigraine headache (OR ranged from 1.3 to 1.9).

CONCLUSIONS

Comorbidity between headaches with a range of physical conditions that have been associated with adult migraine demonstrates that multimorbidity occurs early in development. Comorbidity may be an important index of heterogeneity of migraine that can guide clinical management, genetic investigation, and future research on shared pathophysiology with other disorders.

Migraine and its psychiatric comorbidities

Migraine is a highly prevalent and disabling neurological disorder associated with a wide range of psychiatric comorbidities. In this manuscript, we provide an overview of the link between migraine and several comorbid psychiatric disorders, including depression, anxiety and post-traumatic stress disorder. We present data on psychiatric risk factors for migraine chronification. We discuss the evidence, theories and methods, such as brain functional imaging, to explain the pathophysiological links between migraine and psychiatric disorders. Finally, we provide an overview of the treatment considerations for treating migraine with psychiatric comorbidities. In conclusion, a review of the literature demonstrates the wide variety of psychiatric comorbidities with migraine. However, more research is needed to elucidate the neurocircuitry underlying the association between migraine and the comorbid psychiatric conditions and to determine the most effective treatment for migraine with psychiatric comorbidity.

Neuropsychology of migraine: present status and future directions

Migraine is recognized as a primarily neural condition. Changes in neural physiology have been consistently identified in migraineurs. Numerous studies are available that evaluate physical and functional differences between migraineurs and headache-free controls. The most prominent neuroimaging findings reported in migraine sufferers have been white matter changes. However, physical changes on neuroimaging have not been clearly correlated with functional impairment in migraineurs. The current literature addressing the neuropsychologic consequences of migraine has been far from conclusive, and reports of cognitive testing in adult migraineurs and controls has yielded inconsistent results. Neuropsychologic testing suggests that there may be some subtle but possibly significant changes in cognition that occur both during and between migraine episodes. A finding emerging with some consistency is that migraine patients with aura experience more neuropsychologic deficits than migraine patients without aura. The few studies that assess nonmigraine headache suggest that physical changes may not be unique to migraine, although neuropsychologic changes do appear to be limited to migraineurs. An examination of the unmet needs and priorities for future research addressing this important topic is provided.

Overattachment and perceived disability in chronic migraineurs

OBJECTIVES

The aim of this cross-sectional study was to assess whether stagnation dimensions and depression were associated with perceived disability in chronic migraineurs.

METHODS

Participants were 69 consecutive adult outpatients admitted to the Regional Referral Headache Centre of the Sant'Andrea Hospital in Rome, Italy. Patients were administered the Center for Epidemiologic Studies Depression Scale, the Stagnation Scale, and the Italian Perceived Disability Scale. They also compiled a headache diary to compute headache frequency.

RESULTS

Patients with higher perceived disability (compared to patients with lower perceived disability) reported higher depression and higher symptoms of stagnation. The effect of Overattachment, a dimension of the Stagnation Scale, on perceived disability was only in part mediated by the severity of depressive symptoms.

CONCLUSION

Our results confirm that many patients with chronic migraine report symptoms of stagnation, and that investigating the presence of the stagnation syndrome may be useful for understanding the psychology of chronic migraineurs.

Predictors of outcome in patients consulting their general practitioners for headache: a prospective study

Headache is the most common neurological symptom presenting to general practitioners (GPs). Identifying factors predicting outcome in patients consulting their GPs for headache may help GPs with prognosis and choose management strategies which would improve patient care. We followed up a cohort of patients receiving standard medical care, recruited from 18 general practices in the South Thames region of England, approximately 9 months after their initial participation in the study. Of the baseline sample (N=255), 134 provided both full baseline and follow-up data on measures of interest. We determined associations between patients' follow-up scores on the Headache Impact Test-6 and baseline characteristics (including headache impact and frequency scores, mood, attributions about psychological/medical causes of their headaches, satisfaction with GP care and illness perceptions). Greater impact and stronger beliefs about the negative consequences of headaches at baseline were the strongest predictors of poor outcome at follow-up.

Consultation-liaison psychiatry for patients with headaches

Screening of headache patients for psychiatric disorders is needed, because of the well-known high rates of comorbidity with depression and anxiety. Screening for both depression and anxiety is highly advisable in order to identify subjects who need psychiatric consultation and therapy. Screening tools for depression and anxiety range from informal questions to self-report instruments to structured interviews and the choice is up to the clinician and the setting of the clinical evaluation. Data on psychiatric disorders and medication overuse are till now not consistent. The treatment of mood and anxiety disorders in headache patients needs to take into account the possible drug interactions with headache therapies. The collaboration between neurologists and consultation-liaison psychiatrists helps the identification of headache patients who need a psychiatric therapeutic program and follow-up.

Anxiety disorders in headache patients in a specialised clinic: prevalence and symptoms in comparison to patients in a general neurological clinic

Data from several studies indicate an association of headache with anxiety disorders. In this study, we assessed and differentiated anxiety disorders in 100 headache patients by using the PSWQ (Penn State Worry Questionnaire) screening tool for generalised anxiety disorder (GAD) and the ACQ (Agoraphobic Cognitions Questionnaire) and BSQ (Body Sensation Questionnaire) for panic disorder (PD). Control groups were constructed: (1) on the basis of epidemiological studies on PD and GAD in the general population and (2) by including neurological patients. 37.0% of headache patients had a GAD. 27% of headache patients met the score for PD in the BSQ, 4.0% in the ACQ. Significant results were obtained in comparison to the general population (p < 0.001) and with regard to GAD in comparison with a sample of neurological patients (p < 0.005). The BSQ significantly correlated with the number of medication days (p < 0.005). The results confirm the increased prevalence of GAD in headache patients. PD seems to increase the risk of medication overuse.

Psychiatric issues in patients with headaches

Comorbidities among headaches and psychiatric disorders have been consistently reported in several clinical studies and reviews. In this paper, we review some recent clinical studies on migraine and tension-type headaches associated with mood, anxiety and somatoform disorders, focusing on therapeutic strategies for the psychiatric disorders.

Do psychiatric comorbidities influence headache treatment outcomes? Results of a naturalistic longitudinal treatment study

This study examined if the presence of one or more psychiatric disorders influences headache treatment outcomes in patients in headache specialty treatment centers. Using a naturalistic, longitudinal design, 223 patients receiving preventive therapy for headache disorders completed 30-day daily diaries that assessed headache days/month and severity at acute therapy baseline and 6-month evaluation and also provided data on headache disability and quality of life at acute therapy baseline, preventive therapy initiation, preventive therapy adjustment, and 6-month evaluation visits. Psychiatric diagnoses were determined using the Primary Care Evaluation for Mental Disorders (PRIME MDs). Of the 223 patients, 34% (n = 76) had no psychiatric disorder, 21% (n = 46) were diagnosed with Depression-Only; 13% (n = 29) were diagnosed with Anxiety-Only; and 32% (n = 72) were diagnosed with Depression-and-Anxiety. Prior to initiating new preventive therapy, patients with one or more psychiatric disorders reported more frequent and disabling headaches and poorer life quality compared to patients with no psychiatric disorders. Rates of improvement in headache days/month, disability, and quality of life were significant and comparable across the four groups. Contrary to clinical wisdom, patients with psychiatric disorders respond very favorably to contemporary headache treatments administered in headache specialty treatment centers.

[AC-STB: dedicated software for managed healthcare of chronic headache patients]

This paper examines a new approach to managed healthcare where a network of care providers exchanges patient information through the internet. Integrating networks of clinical specialists and general care providers promises to achieve qualitative and economic improvements in the German healthcare system. In practice, problems related to patient management and data exchange between the managing clinic and assorted caregivers arise. The implementation and use of a cross-spectrum computerized solution for the management of patients and their care is the key for a successful managed healthcare system. This paper documents the managed healthcare of chronic headache patients and the development of an IT-solution capable of providing distributed patient care and case management.

[Anxiety and depression in headache patients. The example of managed care of chronic headache patients in Bavaria]

BACKGROUND

The prevalence of anxiety and depression and the influence of headache severity on these illnesses were examined in patients who were part of the managed care of headache in Bavaria.

PATIENTS AND METHODS

A total of 181 patients with headache were screened for anxiety and depression with the German version of the Hospital Anxiety and Depression Scale (HADS-D). Headache severity was evaluated using the Migraine Disability Assessment Questionnaire (MIDAS). Apart from purely descriptive evaluations, Spearman's coefficients of correlation were calculated.

RESULTS

Of the patients 22.7% and 44.7% obtained results at or above the limit of the normal range of depression and anxiety, respectively and 19.3% had results at or above the limit of the normal range for both illnesses. There were significant coefficients of correlation between the severity of headache and both anxiety and depression.

CONCLUSION

The results confirm the necessity for an interdisciplinary procedure in treating headache patients in order to achieve a successful therapy. Such a treatment can be realised with the concept of managed care.

Psychiatric disorders and headache familial recurrence: a study on 200 children and their parents

The main aim of the study was to examine the relationship between headache and familial recurrence of psychiatric disorders in parents and their children. Headache history and symptomatology have been collected in a clinical sample of 200 patients and their families, using a semi-structured interview (ICHD-II criteria). Psychiatric comorbidity was assessed by DSM-IV criteria. Chi squares and a loglinear analysis were computed in order to evaluate the main effects and interactions between the following factors: frequency and headache subtypes (migraine/not-migraine) in children, headache (migraine/not-migraine-absent/present) in parents, headache (absent/present) in grandparents, and psychiatric comorbidity (absent/present) have been analyzed: 94 mothers (47%) and 51 fathers (25.5%) had at least one psychiatric disorder, mainly mood and anxiety disorders. Considering the significant prevalence of Psi-co in children (P < 0.0001), we compared it with the presence of familiarity to headache: a significant interaction has been found (P < 0.05) showing that migraineurs with high familial recurrence of headache had a higher percentage (74.65%) of psychiatric disorders, than no-migraineurs (52.17%). Absence of headache familial loading seems to be related to psi-co only in no-migraine headache (87.5 vs. 45.5%). The occurrence of psychiatric disorders is high in children with headache, but a very different pattern seems to characterize migraine (familial co-transmission of migraine and Psi-Co?) if compared with non-migraine headache.

Mood and anxiety disorders in chronic headache

Although most individuals with recurrent headache disorders in the general population do not experience severe psychopathology, population-based studies and clinical investigations find high rates of comorbidity between headache and mood and anxiety disorders. When present, psychiatric disorders may complicate headache treatment and portend a poorer treatment response. The negative prognosis associated with psychiatric comorbidity emphasizes the importance of the identification of psychopathology among those with headache beginning at an early age, and suggests that the treatment of psychiatric comorbidity is warranted to improve the outcome of headache management. In this article we describe the mood and anxiety disorders most commonly associated with migraine, tension-type headache, and chronic daily headache. We provide recommendations for the assessment of comorbid mood and anxiety disorders as well as a brief overview of treatment options. Last, we discuss the clinical implications of mood and anxiety disorders on the treatment and outcome of headache.

Basic principles and techniques of cognitive-behavioral therapies for comorbid psychiatric symptoms among headache patients

Recent research on headache has focused on identifying the prevalence of psychiatric disorders in headache patients and discerning the impact of psychiatric comorbidity on treatment of headache. The presence of comorbid psychiatric disorders, especially anxiety and depression, in headache patients is now a well-documented phenomenon. Existing but limited empirical data suggest that psychiatric comorbidity exacerbates headache and negatively impacts treatment of headache. Problematically, these findings have not yet eventuated in improved treatments for individuals suffering from both headache and a psychiatric disorder(s). The present article is an attempt to describe the application of cognitive-behavioral therapies (CBT) for depressive and anxiety disorders to headache patients who present with psychiatric comorbidity. We discuss the origins of the chronic care model in relation to CBT, review basic cognitive-behavioral principles in treating depression and anxiety, and offer clinical recommendations for integrating CBT into existing headache treatment protocols. Directions for future research are outlined, including the need for treatment outcome studies that examine the effects of treating comorbid psychiatric disorders on headache (and vice versa) and the feasibility of developing an integrated CBT protocol that addresses both conditions simultaneously.

A Review of Screening Tools for Psychiatric Comorbidity in Headache Patients

Psychiatric comorbidity, especially depression and anxiety, has been well documented in patients with primary headache disorders. The presence of psychiatric comorbidity in headache patients is associated with decreased quality-of-life, poorer prognosis, chronification of disease, poorer response to treatment, and increased medical costs. Despite the prevalence and impact, screening for psychiatric disorders in headache patients is not systematically performed, either clinically or in research studies, and there are no guidelines to suggest which patients should be screened or in what manner. We review a variety of screening methods and instruments, focusing primarily on self-report measures and those available in the public domain. Informal verbal screening may be sufficient in a primary care setting, but should include screening for both anxiety and depression. Explicit screening for anxiety is important, as anxiety may have a more significant impact on headache than does depression and may occur in the absence of clinical depression. Formal screening with instruments that can identify a variety of psychiatric disorders is appropriate for patients with daily headache syndromes, patients who are refractory to usual care, and patients referred for specialty evaluation. Limitations of screening instruments include the influence of transdiagnostic symptoms and the need for confirmatory diagnostic interview. The following instruments appear most suitable for use in headache patients: for depression, the Patient Health Questionnaire Depression Module, the Beck Depression Inventory-II, or the Beck Depression Inventory-Primary Care; for anxiety, the Beck Anxiety Inventory and the Generalized Anxiety Disorder 7-item Scale; and for multidimensional psychiatric screening, the Patient Health Questionnaire or Primary Care Evaluation of Mental Disorders.

Psychosomatic disorders in developing countries: current issues and future challenges

PURPOSE OF REVIEW

This paper focuses on understanding of the concept, recent advances, and challenges to be faced in the field of psychosomatic disorders by the developing countries.

RECENT FINDINGS

Changing health scenario in developing countries has led to imminent epidemic of noncommunicable diseases along with the unmet agenda of controlling infectious diseases. Psychosomatic medicine has a role to play in curtailing the upcoming epidemic. Research studies on psychosomatic disorders from developing countries are very few. Most of the publications are in nonpsychiatric medical journals covering explorative to intervention studies. Traditional, complementary, and alternative medicines such as ayurveda are already playing their role in the area of psychosomatic disorders in developing countries.

SUMMARY

The role and responsibility of the psychiatrist is changing from treating major mental disorders to preventing and treating psychosomatic disorders. In this regard, developing countries have to meet various challenges such as development of manpower, training of medical and paramedical staff, funding resources for clinical practice and research, coordinating with complementary and alternative medicines, and networking with policy makers in combating the imminent epidemic.

Headache and psychiatric comorbidity: historical context, clinical implications, and research relevance

The comorbidity of headache and psychiatric disorders is a well-recognized clinical phenomenon warranting further systematic research. Affective disorders occur with at least three-fold greater frequency among migraineurs than among the general population, and the prevalence increases in clinical populations, especially with chronic daily headache. When present, psychiatric comorbidity complicates headache management and portends a poorer prognosis for headache treatment. However, the relationship between headache and psychopathology has historically been misunderstood, and measures of psychopathology have not always met the standard of formal Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria. In some cases, headache has been inappropriately attributed to psychological or psychiatric features, based on anecdotal observations. The challenge for future studies is to employ research methods and designs that accurately identify and classify the subset of headache patients with psychiatric disorders, evaluate their impact on headache symptoms and treatment, and identify optimal behavioral and pharmacologic treatment strategies. This article offers methodological considerations and recommendations for future research including: (i) ascribing dual-International Classification of Headache Disorders, 2nd ed. (ICHD-2) headache and DSM-IV psychiatric diagnoses according to reliable and valid diagnostic criteria, (ii) differentiating subclinical levels of depression and anxiety from major psychiatric disorders, (iii) encouraging validation studies of the recently published ICHD-2 diagnoses for "headache attributed to psychiatric disorder," (iv) expanding epidemiological research to address the range of DSM-IV Axis I and II psychiatric diagnoses among various headache populations, (v) identifying relevant psychiatric and behavioral mediator/moderator variables, and (vi) developing empirically based screening and treatment algorithms.

Time-series features of headache: individual distributions, patterns, and predictability of pain

OBJECTIVE

This preliminary study employed "within-patient" time-series methodology to examine headache symptom distributions (peak, sum) to assess predictability of day-to-day headache based on overall pattern, and to better characterize distributional properties of headache as they relate to study design and statistics in future research.

BACKGROUND

Headache symptoms for a given patient may vary widely from one day to the next, ranging from days when the headache sufferer is asymptomatic to days when he or she is functionally disabled with severe headache. Although day-to-day variations are well recognized and appreciated clinically, headache is seldom studied using daily (eg, time-series) methodology that can elucidate potentially important individual and temporal variations. Instead, most headache research has relied upon cross-sectional designs aimed at examining group rather than individual effects which may serve to mask important individual differences. Additional within-patient time-series studies are needed to help identify symptom patterns, clinically meaningful patient subgroups, and relationships among precipitants, interventions, and outcomes. Such research would be aided by delineation of the distributional and temporal properties of key scales (eg, daily headache peak, sum). The present research provides such information derived from clinical samples of migraine and tension-type headache sufferers, laying a foundation for future time-series research.

METHODS

Twenty-five migraine and 24 tension-type headache sufferers prospectively recorded daily headache activity for 1 month. Individual headache distributions were generated and examined individually and by diagnostic group. Predictability for headache was analyzed case by case and summarized by diagnostic group.

RESULTS

The study determined the degree to which individual patients' headache activity distributions deviate from normality (skewness, kurtosis). For migraine and tension-type headache, individual patients' headache patterns were distinctly bimodal in nature. Notably, headache patterns with the lowest frequency were the most bimodal, and as frequency increased, the distributions tended to more closely approximate normal. Patterns were also detailed according to measures of predictability for headache (trends, autocorrelation). Generally, headache days tended to cluster together for both tension-type and migraine (positive autocorrelation) with headache on day 1 being a good predictor of headache on day 2.

CONCLUSIONS

To the authors' knowledge, this is the first study to utilize time-series methodology to characterize individual patients' headache distributions and temporal patterns and to empirically address predictability in this manner. The bimodal distributions noted among less frequent headache patterns would suggest that basic assumptions underlying the use of inferential statistics may be violated when examining intra-individual relationships. Time-series research promises to yield unique insights into patterns, precipitants, and impact of headache disorders, but future research must address both the large degree of individual differences in headache and the account for the unique types of statistical distributions among individual headache sufferers.

Future Directions in Behavioral Headache Research: Applications for an Evolving Health Care Environment

Three decades of research has produced effective behavioral treatments for migraine and tension-type headache, yet the full fruition of this research has not been realized. Further development and dissemination of behavioral treatments is needed to impact the large numbers of those with headache who potentially could benefit from these interventions. At the same time, an evolving health care environment challenges researchers and providers to employ greater efficiency and innovation in managing all chronic disorders. Hopefully, the recently published clinical trials guidelines for behavioral headache research will serve as a catalyst for production of quality empiricism that, in turn, will generate enhanced behavioral strategies and will optimize health care resource utilization. This article describes 10 areas of critical needs and research priorities for behavioral headache research, including: replication and extension of seminal studies using improved methodology; analysis of barriers to implementation of behavioral treatments; development of referral and treatment algorithms; behavioral compliance facilitation with medical interventions; development of a headache self-management model; integration of behavioral intervention within traditional medical practice; identification and management of comorbid psychopathology among headache patients; prevention of disease progression; analysis of behavioral therapeutic mechanisms, and development of innovative treatment formats and applications of information technologies.